Posted
by
timothyon Tuesday June 14, 2011 @08:06AM
from the release-the-hobgoblin-of-little-minds dept.

Lucas123 writes "The change over from a medical coding system in use since the 1970s to an updated version that adds more than 50,000 new 7-character codes is being compared to Y2K as an IT project that is nearly impossible to complete on time. ICD-10, which replaces ICD-9, adds far more granularity to medical diagnosis and treatment. For example, ICD-9 has one code for a finger amputation. In contrast, ICD-10 has a code for every finger and every section of every finger. An 'unfunded mandate,' the change over to ICD-10 codes is a multi-year project for hospitals, state Medicaid organizations, and insurance providers. The effort, which affects dozens of core systems, is taxing IT operational budgets at a time when shops are already under the gun to implement electronic health records."

Surely if the specification lists the data in a structured way, they don't need to be hard-coded. Can't you just stick them all in a database and do lookups? Can't the authority give that the requisite structure?

Surely if the specification lists the data in a structured way, they don't need to be hard-coded. Can't you just stick them all in a database and do lookups? Can't the authority give that the requisite structure?

I'm not so sure of that - one of the big problems would be how do you integrate 9 and 10 digit data so historical records are accurate as well as what happens when systems expecting 9 digits now see 10? There's a huge set of 9 digit data that won't simply go away and systems need to be redone to account for two separate data types. Data entry also needs to still account for 9 digit codes as service delivery and data entry dates could be far apart.

They're versions, not digits. ICD-9 diagnosis codes (for some reason the International Classification of Diseases also has a set of procedure codes) use up to 5 digits in the form [0-9VE]##.##. ICD-10 is of the form X##.###X, except for some codes that have a "placeholder" to pad the middle of the code [wikipedia.org] out to seven digits.

The real problem here is that insurance claim submission is real design-by-committee bullshit of the highest degree. It's an ANSI standard, a submember of ASC X12 so half the shit in there is unused crap needed for the other things X12 is used for, like wholesalers restocking their shelves or boats reporting their cargo, because apparently code reuse is so damn important to these people that the claim form has a section (completely unused for claims) for reporting credit card details. Of course, the insurance companies all took this design under advice and did their own shit with it. There's a code that identifies whether the insurance company is blue cross, medicare, medicaid and so on (that you have to put on the claim just in case blue cross forgot, and they apparently forget a lot, since if the clinic forgets to set this code properly, the insurance company uses every excuse possible to refuse to pay). Simple enough, right? Well when I started, we had an insurance company that used blue cross's servers for processing claims, so even though they weren't blue cross, this code had to be blue cross or BC's servers would shit themselves. Setting that aside, there's a completely separate code for what kind of provider ID you're sending (blue cross, medicare, medicaid and so on) because of course people are going to bill blue cross using medicaid IDs. Fortunately, the NPI did away with that bullshit (for the most part... medicaid here still demands provider IDs for checkups because they refuse to give up any hoops for doctors to jump through, and one of those was that the doctor had to use a different provider ID for checkups versus treating someone sick. Their computer system apparently cannot sort these claims out themselves... and yet if you bill a checkup on the wrong provider ID, the computer system can easily reject it. Hmmm...)

Ahem.... Anyways, instead of just adding a code to identify whether the diagnosis in question is using ICD-9 or ICD-10 (in the box the committee already created for the purpose of identifying the code being used), the committee got together and pretty much rewrote the whole damn thing. This is where IT got gummed up (it's getting better now). And believe me, you can talk about "legacy equipment" and other stuff til you're blue in the face, but claim submission is how doctors and hospitals get paid, that's where IT has been spending all of its time freaking out.

It's not just that a bunch of codes have been added or removed. The relationships between the codes have changed as well. What used to be a single code in ICD9 may have been replaced with a list of codes in ICD10 (or, worse, a tree structure of codes); and conversely, what used to be a dozen codes in ICD9 might have been replaced with a single code. The disjoint mapping of codes and their relationships is what's really gumming up the works.

"CD-9 has one code for a finger amputation [. In contrast,] ICD-10 has a code for every finger and every section of every finger.
Yikes! Perhaps the standards authors should have considered the principle tenet of the hypocrite oath: "First, do no harm!"

simple, run date check, add a leading zero if before set date. If data is modified prompt for new code before saving. Not all old data will have enough information to be moved to the new system but this makes migration pretty simple. Only thing left is correlate old and new code categories which is probably tedious, but should be pretty straight forward.

simple, run date check, add a leading zero if before set date. If data is modified prompt for new code before saving. Not all old data will have enough information to be moved to the new system but this makes migration pretty simple. Only thing left is correlate old and new code categories which is probably tedious, but should be pretty straight forward.

While in theory data migration sounds easy; in practice it is far more complicated. I did a project for a financial migration where SSN's were used as employee ids (US company); so the IT types used that as the key to create the new records. After they did that they discovered so many duplicate records that manual analysis took forever. At first they did not believe my rule of 10's when it come to data migration - it will take 10x as long, cost 10x as much as in the plan and you will delete at least 10% o

Yes, that's the easy and obvious part. Keeping both versions of the ICD9 code sets around is standard practice. The hard part involves the people and training issues related to phasing out legacy applications which are hard-coded to reference the old ICD9 codes.

You don't work in the medical field do you? ICD codes are built into a lot of medical applications. For a famous slash dot car analogy, this is like trying to convert a U.S. car manufacturing plant over to use all metric.

I don't see any "sense" in adding codes merely to tell the doctor which finger was amputated. All he has to do is LOOK and see for himself which finger is missing. This is typical government "make work" bureaucracy that makes no more sense than going-round and busting windows to boost construction jobs.

It's also what bankrupted the treasury and led to the downfall of the Roman Empire (according to one historical theory).

I had a finger amputated. Tell me which one. Go on, just LOOK, after all, that's obvious, right?Not like there's ever a situation where that information, individually or aggregated, might be useful to anyone in the spheres of research, information or analysis, without the patient in front of them, waving. And if it is, we can just line up all the amputees and they can look at them one at a time.Alternatively, maybe it'd be handy to code this stuff up.Just be grateful its ICD and not SNOMED CT, which contain

What if more than one finger is missing, say one was lost in an accident and another had to be amputated? How would a doctor tell them apart without that being recorded? What about things like broken bones that have been set? It could be diagnostically important to know which bones have been broken and how they were fixed, but that's not visible from the outside.

Assuming the doctor is there, and not looking at info on a computer, or that the insurance needs to know, other thousands of other reason people would be looking at record when the patient isn't there.

Like anyone who speaks outside their experience and expertise, you look like a complete and utter moron.

This is typical government "make work" bureaucracy that makes no more sense than going-round and busting windows to boost construction jobs.

So your example of the typical government "make work" program is something that never happened?

It's absurd how medicine is practiced in the US today - two trillion dollars per year and most decisions made by the seat of the pants, with little or no cost/benefit analysis. We need to adopt Evidence-Based Medicine, and that requires information to determine the most c

Also the insurance company that has to compensate the guy who lost the finger(s) might like to know which one(s) were amputated and how much was amuptated. They pay different amounts for different fingers and different amounts depending on how many joints were lost.

Also the insurance company that has to compensate the guy who lost the finger(s) might like to know which one(s) were amputated and how much was amuptated. They pay different amounts for different fingers and different amounts depending on how many joints were lost.

Hehe... another person who doesn't work in the medical IT field, eh? If only. Ever heard of the Food and Drug Administration? They have this thing called 'FDA Approval' for software products. The change in format structure from ICD9 to ICD10 generally requires all the vendors of these systems to re-certify.

While these systems *should* be flexible enough to handle the code format changes, most of them aren't, due to federal certification and litigation reasons. The medical community would rather ha

Because, you know, changing configuration items never breaks software. It's just configuration! If it's important, hardcode it like a boss!

Sorry, you fail at basic configuration management, let alone certifiability for life-and-death purposes. You fix a configuration or a narrow range of configurations and certify that specific configuration. You don't let field weenies free-lance on your gamma knife or intravenous infusion pump.

The process is fine. Recertification is a valid cost, considering the safety im

The question isn't so much whether or not to design a system to be resilient to change, it's about exactly how resilient it should be.In Y2K, many year fields were update from 2 to 4 digits. When the year 10,000 comes, we'll have to eat the cost of our poor design choices again.Obviously, it completely unrealistic to expect any current software to run in the year 10,000. Just as it was completely realistic back in the 70's and 80's to expect any current software to run in the year 2000.Perhaps a bit extreme

The article is actually pretty comprehensive and gives specific examples. I can easily see how this can turn into a nightmare. Everything in the hospital has to understand the new language. It has to be in the administrators excel spreadsheets, and the laptops used by the ambulance drivers, and the x-ray equipment. All the interfaces need to be validated because fuckups cost lives.

Medicare, like any insurer may change it's paperwork in an effort to make the process more accountable. As it's an international standard that has already progressed to ICD-10-CM, it's probably about time.

True.
As an IT guy who worked for a medical billing company I got to see the inner workings of the coding world.
It is interesting to see that it requires another human being to code from a doctors notes. And then many things came into play, such as alife medical, a EMR system that codes based off of what it reads. They even converted TIFFs with OCR so they could read it. Now with things like NextGen you can put it all into the system and let the system do it for you. No more "interpreting" what the doctor wanted to say. However, with this system it will be tough to find doctors who overbill or put in information that is untrue.
I would watch coders detect these things by finding a doctor attempting to charge for a procedure that did not even involve the issue. Can an EMR system do that? Hopefully, but it will probably be an after thought to the new coding.
And what about these certified coders? Do they have to retrain and re-certify? Probably.

That job was an eye opening experience into the Medical billing world. It was very interesting and I helped develop some of the very first medical billing methods.

Unfortunately, the old ICD9 is considered broken, so it's not suitable for supersetting. As an example, say that the skull is considered part of the head in ICD9, but the skull is considered part of the skeleton in ICD10. The code for skull has moved from 'head' to 'skeleton'. How do you superset that kind of relationship change? Worse, what if the original ICD9 relationship is considered no longer scientifically valid? What if a disease of an organ is reclassified to be a disease of blood? Or of the

An 'unfunded mandate,' the change over to ICD-10 codes is a multi-year project for hospitals, state Medicaid organizations, and insurance providers. The effort, which affects dozens of core systems, is taxing IT operational budgets at a time when shops are already under the gun to implement electronic health records."

This is good as well. Insurance company profits are ridiculous and hopefully this will force them to invest a lot of those profits in the American economy to do this work. Complaining about expense when replacing systems in a organization that is fraught with malpractice (misdiagnosis, amputating the wrong limb, dispensing the wrong medication) is ridiculous. This is akin to the government complaining about the cost of replacing infrastru

Actually Insurance companies wont be involved in re-engineering the medical coding.
They just get the bill.

Not true. The insurance company I worked for had a 3 year project to implement ICD-10 and it went relatively smoothly, and was not any more difficult than any of our other IT projects. It's just a project like any other project. Planned, budgeted, executed. Nothing to see here.

What TFA and other commentors don't seem to get is that the health industry is *massively regulated* and beurocratic. They have to deal with things like this *all the time*.

The misattribution of the reason for rising costs in health care is unfortunate. The fact that government as a payor is in this system is one of the main reasons costs rise as such a rate.

I work on the revenue side at a fairly large health system, and due to our population we have approximately 50% of our patients privately insured, and close to 50% are government insured. (There are very few people coming in the doors who truly have no coverage, despite what the politicians would have you believe). The privately insured generally repay approximately what's billed, but for the government paid accounts, we would do well to recover 50%, 40% is a better guess. This is because the government solves its own budgetary problems by withholding increases to its medical payouts. In this area, we're still being paid at 2002 rates in 2011. We never withhold a needed service, so we just eat the cost.

But we have to make the books balance somehow. We're non-profit, but we still have to keep the lights on. Charge rates have to go up across the board, and the money lost on literally every government paid patient who walks in the door is then made up by the privately insured. You hear about $8 tylenol being billed, well, tylenol has to cost $8 because you're actually buying a whole bottle and sharing it with everyone else.

I think we're going to continue to have a huge gap of misunderstanding while people continue to emote over "big business" and "fat cats" and "obscene profits" without understanding what the real financial issues are on the ground.

Every system in the developed world has a private spending component, usually through insurance and copays just like here, but most also have a government payer either as the single payer or more commonly as a backstop, last resort payer; all systems more firmly regulate costs and practices and all systems at least have independent boards to assure efficacy of treatments (we call those "death panels.") There's no empirical evidence that people make rational decisions about their own health care spending.

The insurance companies will only use this as a reason to raise rates. I presume in the long run it will make the system more efficient, but I do not believe it will make it cheaper simply because the insurance companies will eat any efficiencies and fail to pass them on to the consumer or the taxpayer.

If insurance companies were good for the health system, it would be fixed by now. They aren't and they need to be kneecapped.

As a quick note, misdiagnosis and malpractice are very rarely related. The other two things you list are gross misconduct. The wrong amputation is pretty rare but a devastating event. The wrong medication is much more common, but is rapidly becoming LESS common at least in hospitals with multiple error checks in the system to prevent it. Many modern medication administration records software systems force the administrator to verify identify via barcode scanners etc and then verify the drug using the sa

This is good as well. Insurance company profits are ridiculous and hopefully this will force them to invest a lot of those profits in the American economy to do this work. Complaining about expense when replacing systems in a organization that is fraught with malpractice (misdiagnosis, amputating the wrong limb, dispensing the wrong medication) is ridiculous. This is akin to the government complaining about the cost of replacing infrastructure when the alternative is your car plunging in the river on your morning commute.

Insurance companies are not the villains making an obscene 5% profit, they will probably increase profit once this system is in place as they only have to change a few programs, over billing and other risks will be mitigated due to better identification of injuries. Hospitals and other health care providers are the one's who will feel the pain as they have to update all their systems many of which hard coded the values in and so every program has to be updated and tested to the medical standards (which is w

Insurance companies (or their subcontractors) will invest exactly enough money to make their systems find any inconsistency or miscoding in the insurance claim and reject the entire claim on that basis. They will not help hospitals or other care providers update their systems.

For example, my mother works in a small town pharmacy. One insurance claim was rejected by an insurance auditor because the date that the patient picked up the prescription was written on the back of a form rather than the front. It

Having the code would make it possible for systematic checks to occur (say, a bar code not matching the medical procedure listed in the patient's file.)

Huge taxonomies always seem to make a lot of sense to the people who make the reports or design the "systematic checks" you mention. In real life, however, the workers are pressed for time and will take the path of least resistance. If that means selecting the first instance of "finger" that appears on the list, then so be it. One can hope medical professionals wouldn't be that way, but I suspect some aren't as respectful of your database values as your reports might require. The almost universal relian

There are already bar codes, double and triple checks by various personnel, and in some cases the patient actually marks with a sharpie which knee it is they will have surgery on, for example. Everywhere in the case the "laterality" (can't recall what the technical word is) is spelled out. It's really amazing that any of those errors occur. This was always rare but exponentially less so 30 years ago, today it is exceedingly, exceedingly rare.

Actually, it's probably more amazing that more don't occur. I've done post event investigations numerous times; and left/right top/bottom mixups are not that unusual. The clinicians I've worked with recommend the Sharpie method, as well as making every person who comes in contact with you properly clean their hands in your presence.

Coding, is just a manner of recording in a concise format, what diagnosis was made, and what treatment was given. This way the data can be used for billing and statistics.

I have never, ever seen medical codes (be them ICD9, ICD10, SNOMED) ever used by doctors, medical technologists, or anyone with any direct influence over patient care. They aren't used in X-ray equipment (so there's no risk of incorrect examinations or incorrect interpretation), blood-work analysis machines, etc.

Being an MD, and part-time software developer, I've done a lot of work with medical databases. I looked at coding of educational files, and being able to import selected educational cases directly out of the hospital's electronic record system, in anonymised fasion, into an educational system. The first thing I noticed was that the coding (in this case ICD9) was extremely inaccurate, and often wildly misleading - fewer than half the codes I looked at were correct. The reason was that the coding was done by clerical staff, who read through the charts, and worked out what codes to use. These clerical staff weren't doctors, nurses, or other people trained in medical diagnosis. As a result, they would frequently misinterpret the charts and the wrong codes would be sent to billing and for government health statistics.

The effort, which affects dozens of core systems, is taxing IT operational budgets at a time when shops are already under the gun to implement electronic health records.

For the most part, this isn't my problem.

ICD-10 has been on the radar for a while now. At least a couple years. And it's Federally mandated. So we didn't have any problem adding the necessary funds to our budget this year.

Each of our HIS vendors has already got ICD-10 stuff ready to go. We'll have to pay them for their time, or a software release, or whatever... But, as far as my own labor is concerned, it'll basically involve giving them remote access or throwing a disc in the drive.

Most of the labor involved is in our coding department. They're going to have to send folks out to get (re)trained in the ICD-10 stuff. They are, understandably, a little stressed. But they've been working on this for a while, too.

As the spouse of a Physician (hospitablist) and a System Admin for a medical practice, I can tell you first hand that is a cluster f&*%. The effect this crap is to slow down physicians with tasks that they really should not be doing, (read data entry). That is exactly what these regulations are doing. And to keep productivity up, some doctors are resorting to hiring scribes who follow them around, just increasing costs that will get absorbed somewhere. It all looks good on paper but the effect is r

As someone who's working with this stuff right now, I can say if it's slowing you down, you're not taking advantage of the available tools. They're out there. Keep looking.
Moreover, "data entry" is one way of looking at it. A different way to call it is "documenting what they're doing with sufficient detail". That was the entire point of these kinds of standardized coding systems: to (as best as we can) remove the fuzzy documentation in the systems before, and to remove the idiosyncrasies from medical records. With the proper coding systems in place, a patient in Allentown who moves to Duluth can have his PHI moved to the new caregiver and be (for the most part) confident that the Iowans will be able to understand what the Pennsylvanians did for him before.
Yeah, there's going to be transitional pain. There always is. But as has been pointed out in other posts, it's not like ICD-10 ambushed anybody. Frankly, if you haven't been moving toward ICD-10-capable systems for at least 2 years, you've been slacking. There's a penalty for that at crunch time.

being compared to Y2K as an IT project that is nearly impossible to complete on time.

That sounds like good copy to a lowly journalist, but as someone "who was there" during Y2K, what was "nearly impossible"? We knew it was coming, we planned, the bosses mostly used it as an excuse to semi-fraudulently ram upgrades thru and as a powerful weapon to grab more budget money. It was way, big time, trivial.

Besides, just think about it. The entire world's IT department, all those guys who can't close open relays, blah blah blah all somehow 100% successfully did the nearly impossible... yeah uh h

Amen to this. I got hired on by a company on Madison, WI in January of 1999 and was told on my first day that "this Y2K thing" was my first priority, since my predecessor had put in maybe 3 hours of work on the project. Oh, and I had to do it while getting our network up to date.
Frankly, it was a cinch, once they'd approved the budget. *That* took until June, too, so I really did the entire project in 6 months.

ICD-10 has been out for nearly 20 years. There was a 5 year timeline to get ICD-10 implemented, and there was likely a few years of discussion with major Medi* billers before that to let them know this was coming along.

Much like the FCC and HDTV, health care companies must have ignored the mandates until it was too late, whined and cried about how they couldn't meet such a strict deadline and pretty please can we extend it for another 5 years. Repeat until our health care records system is completely unusable.

Though, wow, I would have thought VistA would have ICD-10, but it's being bolted on now. Strange.

It appears to me that most hospitals/medi orgs were dragging their feet to see how it would play out:

"Quite frankly, the hold up is it's a big undertaking and it took them a while to get under way. Everybody's started, but a large percentage of hospitals are in the heavy analysis stage or they're just starting," said Casey Corcoran, vice president commercial solutions for healthcare at General Dynamics Information Technology, a vendor offering ICD-10 consulting services.

Do you have any idea how some medical centers operate? The small ones are usually nimble enough to change on a drop of a hat. It's the big ones that use many, many closed source, proprietary software for records and then hire loads of contractors to write more closed, proprietary middleware to link them all together that are going to have the problems. Most of these medical software companies go out of business after having sold their 'product' to about 2-5 large clients so finding somebody that understands

If you really have a problem with extending a field by a few bytes, you're using the wrong language. By now, you should expect the world is going to change constantly. If it's a surprise to you at this point congress is going to re-invent healthcare ever two years to boost their ratings, please beat yourself with your keyboard.

Let me guess, the people complaining are using z/os hardware and wrote everything in cobol accessing a ADABAS database. Some idiot business manager said, "It ain't broke, lets not u

When I left the hospital IT in the last decade, they were still writing everything in a niche language developed in-house by a power company in the next state. Nothing in the way of data integrity developed since the 60's with relational databases, and all of the productivity of a 40 year old language. This was the largest healthcare organization in the state.

Oh, they were going to upgrade to Visual Basic for some of the new code when I bolted for the door. Those who understood computer science were revi

See, that attitude is the problem.When I worked in healthcare, I used good software design. If a MD wanted to change things, or wanted me to do it differently, I just asked them if they would personally take the liability if it cause someone to die.

Yes I pissed off a lot of MDS. and they stayed pissed all the way up until the started using my software; At which point they get a lot friendly, and on TWO separate times I got an apology. Wish was quite shocking.

Not directly but by buying whatever sales guy got chummy with the PHB and insists will fix everything. It generally cost more does less, is a giant pita to make work and follows no standards even there own.

As pretty much everyone else has already said, if you don't have a system that can quickly and easily update from ICD-9 to ICD-10, you're so far behind the IT implementation curve that you should be drug out into the street and shot.

It's 2011. They've had many, many years to upgrade, and now they're poised to paid by the government to do so. Hell, my employer stands to gain $50 million dollars over the next couple years from implementing key portions of the HITECH provisions in ARRA. For those reading, that's more than half of my (quite large and well-funded) health system's annual budget.

For our part, we just slapped down a couple hundred thousand for a product that hot-swaps our ICD-9 coding for ICD-10, and also tosses in a problem list that physicians can use that's tied to these coding schema, potentially improving efficiency and accuracy as well. The only excuse, and I mean ONLY excuse for ICD-10 being a problem is poor IT leadership within the health system/hospital--a failing which is incredibly, unbelievably common.

I thought the 2009 stimulus package had $30 Billion which was to be paid to hospitals to update their systems? The only backup I have for this is an I, Cringley [cringely.com] article I read over the weekend but I'd feel he'd of all IT writers would be a reasonably reliable and impartial source. Definitely a far more reliable source than the average Slashdot submission.

FYI, this really doesn't affect the diagnostics. 98%+ of it has to do with billing. Just because there was only one code for amputating a finger doesn't have anything to with the doctor doing his job. He does cuts it off describes what was done in the chart(or EMR) then after the person is discharged a person in a little room called a "coder" goes through the chart and enters the billing code(ICD-9 currently) in the bill that gets sent off to the insurance company.

Stuff like this is like infrastructure, the private companies will wait until it is completely disintegrating then try to get someone else to pay for it instead of spending money that could better be used for bonuses on capital improvement projects. ICD-10 was finished in 1992 [wikipedia.org]. So we're not stuck in the 70s, we're stuck in the 90s.

It doesn't help that all the private insurance companies have hitched their trailer to Medicare and do "whatever Medicare does", w

What is the ICD-10 code for being a dickless idiot. They could save time by automatically adding it to the record of all Federal employees. OK - maybe not the FBI - honestly I didn't mean you, I was just sayi.....

The ICD-10 codes for being a dickless idiot would be:Q56.4 Indeterminate sexF79.1 Unspecified mental retardation with significant impairment of behaviour requiring attention or treatment

Hello, I am a surgeon, and I can tell you a lot of the cost is from all the middle men (ins companies), and defensive medicine. It's not the doctors who are making the big bucks. One of my patients said to me.
"Yeah Doc, the bill was big, but your part of the bill was peanuts - I feel sorry for you."

Most MDs pay about 10% off the top of profits for a billing service because it's so complex.Many additional x-rays, lab tests are also ordered because we worry about "missing" something, and be